Substance abuse has become an increasingly prominent concern of Denver policymakers in recent years.  Momentum has been gathering in support of significant new investments to reduce alcohol, tobacco and other drug problems.  In January 2002, Mayor Wellington E. Webb declared that the fight against addiction would be a major emphasis of his final year and a half in office.^[164]  The Mayor proposed nearly $1 million in new spending on prevention and treatment initiatives, despite the recent economic downturn and the resulting budget constraints.  Mayor Webb underscored his determination to keep the focus on substance abuse by moving the city’s drug strategy coordinator from the public safety office into the mayor’s office.

These announcements marked the culmination of deliberations set in motion in the Spring of 1998, when Mayor Webb established a commission to assess Denver’s substance abuse needs and recommend appropriate strategies.  In 1999, the commission called for a collaborative approach in which enhanced prevention programs and expanded treatment capacity would complement ongoing enforcement efforts.^[165]  The commission also urged broad community involvement in shaping specific strategies, and counseled that each strategy should be research-based and include measurable goals.  To guide the process, the commission advocated the creation of the city’s own drug policy leader. In July 2000, the Mayor acted on this advice, naming Adam Brickner as Denver’s first Drug Strategy Coordinator.

Since then, a task force of city officials, business leaders, service providers and community representatives convened by Mr. Brickner has met regularly to frame an overall substance abuse strategy for the city and to establish policy priorities.  The task force has set five major goals:

·                      Educate Denver’s diverse community to make healthy choices about substance use, abuse and the disease of addiction.

·                      Identify and reduce gaps in substance abuse and addiction services.

·                      Provide links to substance abuse prevention, intervention and treatment services.

·                      Support the enforcement of laws and policies to improve the quality of life in relation to the use and abuse of alcohol, tobacco and illegal drugs.

·                      Encourage employers to enact proactive substance abuse policies and programs.

The strong emphasis placed by the task force on improvements in prevention and treatment services is reflected in the Mayor’s push for new funding in these areas. 

Greater Investment in Prevention and Treatment Supported by Research

The growing support in Denver for enhancing local prevention and treatment efforts is animated by the recognition that city residents are already paying dearly for substance abuse problems.  As the previous chapter documents, alcohol, tobacco and other drug abuse costs Denver residents, businesses and government at least $1.5 billion every year.  A growing body of scientific research shows that prevention and treatment are cost-effective in reducing the burdens substance abuse  imposes on society, and therefore they merit substantially increased investment.

The Case for Prevention and Early Intervention
To the extent that young people never begin using alcohol, tobacco or illicit drugs in the first place—or delay initiation of use until they are older—the number of people who eventually develop substance abuse and addiction problems can be substantially reduced.  Age of initiation is a powerful predictor of substance abuse problems later  in life.  Almost all first use of tobacco occurs before the end of high school.  Those who do not begin smoking during their adolescent years rarely do so later.^[166]  Youth who begin drinking early (before age 15) are four times more likely to develop alcohol dependence than those who begin at age 21.^[167]  Each year’s delay in initiation of drinking greatly reduces the likelihood of later alcohol problems.  So, too,  for marijuana.  According to the 1999 National Household Survey on Drug Abuse, among adults who first used marijuana before age 15,  9 percent were dependent on an illicit drug in the past year, compared with fewer than 2 percent of adults who first tried marijuana at age 18 or older.^[168]

A wide range of policies and programs have proved effective in preventing or delaying substance use, and in discouraging experimental users from progressing to more frequent use.  For example, research has shown that youths and young adults are especially sensitive to alcohol and tobacco price increases.  Raising the price of cigarettes and alcohol through higher excise taxes reduces rates of youth smoking and drinking.^[169]

The Case for Treatment
Denver’s increasing emphasis on treatment is supported by three decades of scientific research and clinical practice demonstrating treatment’s effectiveness.^[170]  By its nature, addiction cannot be fixed the way a broken leg can be set and healed.  Once a broken leg is mended, we do not expect that the leg will break again.  Because addiction is a chronic, recurring disorder, the ultimate goal of long-term abstinence requires ongoing management, as is the case with other chronic disorders, such as hypertension and diabetes.^[171]  By reducing drug use and the corresponding social damage, treatment confers real benefits, especially when compared to the alternative—non-treatment and unchecked drug abuse.

The most recent national, multi-site evaluation—the National Treatment Improvement Evaluation Study (NTIES)—examined results for more than 4,400 patients in treatment between 1993 and 1995.  The study found that the proportion of patients using any drug dropped by 41 percent in the year after treatment.  Significant reductions also occurred in the proportion of patients selling drugs (down 78 percent), arrested on any charge (down 64 percent), requiring medical care due to alcohol or other drug use (down 54 percent), and being homeless (down 42 percent).^[172]

The benefits of treatment far exceed the costs.  A landmark 1994 study, The California Drug and Alcohol Treatment Assessment (CALDATA), found that every dollar invested in treatment saved taxpayers seven dollars in future costs.  CALDATA researchers concluded that “each day of treatment paid for itself ... on the day it was received, primarily through an avoidance of crime.”^[173]  In the NTIES treatment evaluation, treating low-income clients created a net savings of more than $6,200 per client—due to reduced spending on health care, welfare and crime-related costs—with a three-to-one ratio of benefits to costs.  Based on these findings, NTIES researchers estimate that public treatment services supported by federal funds in 1994 generated a net benefit to society of $1.7 billion.^[174]  Treatment is also cost-effective compared to other drug control strategies that compete for public funds.  As a means of reducing cocaine consumption, the RAND Corporation has found that treatment for heavy cocaine users is 23 times more effective than drug crop eradication and other source-country programs, 11 times more effective than interdiction and 3 times more effective than mandatory minimum sentencing.^[175]

People typically enter treatment when the adverse consequences of alcohol or other drug abuse or addiction compel them to seek help.  For many, this may be some personal calamity (job loss, marriage breakup, legal difficulties or health problems) if they fail to curtail their substance use.  Those arrested for criminal activity may be compelled to enter treatment by court order, or offered the chance to participate in treatment rather than face full criminal prosecution and the threat of incarceration.

Treatment can work whether a patient enters freely or under coercion from the criminal justice system.  Most of the research on treatment outcomes has dealt with patients who entered treatment voluntarily, but several recent studies have demonstrated the effectiveness of coerced treatment as well.^[176]  Indeed, involvement in the criminal justice system presents a prime opportunity to engage drug users in treatment.

The Role of Enforcement

While emphasizing the need for greater attention to prevention and treatment programming, Denver’s strategic goals do not neglect the important role of enforcement in limiting substance abuse.  Laws prohibiting the use, possession or sale of many substances (such as cocaine), and legal restrictions on who can use alcohol (minimum legal drinking age laws), enjoy wide public support and undeniably limit the prevalence of substance abuse.  For example, the vast majority of Americans (89 percent) have never used cocaine, according to the National Household Survey on Drug Abuse.  Even marijuana, by far the most commonly-used illicit drug, has never been used by two-thirds of Americans.^[177]  Researchers credit the shift to a minimum legal drinking age of 21 in all 50 states with having prevented some 700 to 1,000 traffic fatalities each year for the past decade, and with having contributed to a sizeable decline in past-month drinking and binge drinking among high school seniors nationwide.^[178]

At the same time, Denver’s push for expanded treatment services recognizes the limits of the  emphasis on intensified enforcement that has dominated the American response to drug abuse since the 1980s.  During this period, the number of casual users of illicit drugs has declined considerably; the number of occasional (less than monthly) cocaine users fell from an estimated 7.1 million in 1985 to 1.7 million in 2000.^[179]   But in recent years, heavy drug use has remained fairly constant.  The number of chronic cocaine and heroin users (more than 10 times a month) declined only slightly between 1995 and 2000, from 3.8 million to 3.6 million.^[180]

Tough-on-drugs rhetoric and policies have hardened attitudes toward heavy drug users, pushing them further to the margins of mainstream society, and increasing the adverse consequences of their drug use.^[181]  This marginalization is borne out in the steeply rising rates of drug-induced deaths and drug-related hospital emergencies since the late 1980s.  Since 1988, when intensified drug enforcement was well underway, the annual rate of drug-related deaths has risen by more than 55 percent, while the rate of cocaine and heroin-related hospital emergencies has climbed by 71 percent.^[182]

Putting more drug dealers behind bars was supposed to make illicit drugs harder to find, thereby reducing drug use and its related harms.  Incapacitating enough dealers and deterring others from selling drugs would, in theory, make drugs more scarce and more expensive.  But with an illicit  commodity such as drugs, locking up one distributor simply creates a job opening for someone else.  The openings created by incarcerating low-level street dealers are readily filled by replacements from the same drug organization or from a competitor.  Even when replacement is not immediate, remaining dealers can pick up the slack in the local market by selling more drugs themselves.^[183]

Nationally, retail prices for cocaine and heroin are now about half and two-thirds their 1981 levels, respectively.^[184]  Crack, singled out for particularly tough sentencing in federal law and in some states, is no more expensive at the retail level than powder cocaine.^[185]  Moreover, high school seniors nationwide report that crack is as easy to obtain now as it was in 1987 at the height of the crack epidemic, and that heroin is significantly easier to get now.^[186]  In Denver itself, the street prices of crack and heroin have essentially not changed since the mid-1990s.^[187]

Pursuing a Comprehensive Strategy

Denver has made significant strides in pursuing a comprehensive strategy that balances the historically predominant role of enforcement with new investments in prevention and treatment services.  A variety of programs are already in place or being readied for implementation with the goal of ensuring access to the full continuum of substance abuse services—including prevention; early intervention; treatment; and transition and recovery.  Illustrative efforts in each area (not an exhaustive catalogue of relevant city programs) are noted below.

Prevention
·                      Denver Public Schools utilize one of the nation’s most extensively evaluated substance abuse prevention programs, Life Skills Training (LST).  The LST curriculum focuses on providing upper elementary and middle school students with the personal and social skills to resist peer and media pressure to use alcohol, tobacco and marijuana.

·                      Denver high schools are launching a Social Norms Project (SNP) to accentuate the healthy behaviors of the vast majority of youth, and correct student misperceptions of the extent of alcohol, tobacco and other drug use among their peers.

Early Intervention
·                      Another school-based program, CASASTART, focuses on elementary and middle school children identified as being at especially high risk of substance abuse and delinquency.  Case managers provide at-risk students with a variety of services geared toward improving school performance and expanding opportunities for positive engagement with school, peers and the community.

·                      Denver’s Safe City Office intervenes with Denver youth at risk of involvement in the juvenile justice system.  Youths who violate curfew or other municipal laws are offered counseling, assessment and referral services in lieu of facing charges in court.

Treatment
·                      The Denver Drug Court was created in 1994 to handle drug felony cases that do not also involve non-drug crimes.  The Drug Court facilitates quick action on all drug cases, so that defendants can enter treatment programs rapidly and avoid being sentenced to jail or prison.  Direct court supervision, regular appearances before a judge and weekly random drug tests encourage Drug Court offenders to remain in treatment.  An estimated 1,500 Denver residents participate in treatment each year through the Drug Court.  The number of Drug Court participants who successfully complete the program, test drug-free and graduate has risen steadily, while the number eventually sentenced to prison has declined.  In 1995, only 19 percent of participants graduated and 81 percent were sent to prison.  By 2001, 75 percent of participants graduated, and only 25 percent went to prison.^[188]

·                      Denver is one of 15 cities nationwide to win designation as a Demand Treatment site, with funding from the Robert Wood Johnson Foundation to support efforts to bring more people into treatment.  The Denver Medical Center and its 11 family health centers are training physicians, nurses and other medical staff to recognize substance abuse problems and refer patients to assessment and treatment services.  The city will also enhance its website with tools for self-evaluation, problem recognition and service referral.

Transition and Recovery
·                      In Spring 2002, Denver was awarded a federal grant to enhance treatment and other support services for women involved in the criminal justice system.  The program, known as “Miracles,” will provide 150 women with intensive outpatient treatment and case management designed to improve participants’ self-sufficiency and overall health.

·                      Denver is also planning a program to target homeless youths involved in substance abuse who require a supportive environment to sustain the benefits of detoxification and treatment.  Many treatment programs are geared toward older clients, and shelters are a difficult environment in which to avoid relapse.  Through Starting Transition And Recovery (STAR), homeless young adults in recovery will have access to a transitional living facility conducive to remaining engaged in treatment and gaining the skills  and confidence to eventually live independently.

The Deadlock Over Syringe Exchange
Despite a significant number of Denver residents who are injecting drug users (IDUs) and a rate of newly diagnosed drug-related AIDS cases that is double the national rate, Denver does not have a syringe exchange program (also known as needle exchange).  Such programs curb the spread of HIV by decreasing syringe sharing and other HIV risk behaviors.^[189]  Syringe exchange can also be an effective bridge to treatment.^[190]  The National Institutes of Health, the National Academy of Sciences, the Centers for Disease Control and Prevention and researchers at Johns Hopkins University have found that syringe exchange programs effectively reduce the spread of HIV and hepatitis-B without increasing drug use or other public safety risks.^[191]

In 1997, the Denver City Council authorized the operation of syringe exchange programs in the city, providing that programs register with and be regulated by  Denver’s  Environmental Health Department.  However, to date Denver has no licensed syringe exchange programs because the  city authorization is in conflict with state law on drug paraphernalia (any device used to grow, manufacture or ingest illicit drugs).  Under current Colorado  law, distribution of drug paraphernalia —including syringes—is a misdemeanor punishable by three months to one year in jail and/or a fine of $150 to $1,000.^[192]

The Role of State Policy

Denver’s ability to mount a comprehensive campaign to reduce substance abuse and addiction is strongly affected by the state government’s  priorities.  As Colorado’s largest city, Denver has the resources to pursue significant improvements in its prevention and treatment capabilities.  But the active support of the state government—which can bring far more resources to bear—would  provide a crucial boost to the city’s efforts.  In recent years, state legislative policy and budget priorities with regard to substance abuse have been oriented far more toward enforcement and criminal justice sanctions than toward treatment.

Tobacco Prevention and Control
The Centers for Disease Control and Prevention (CDC) provides guidelines for all states to pursue comprehensive tobacco control programs.^[193]  The strategies recommended to prevent initiation of tobacco use, promote quitting and eliminate non-smokers’ exposure to environmental tobacco smoke are based on evidence from programs already underway in various states.  According to the CDC, Colorado could mount a comprehensive tobacco control program based on best practices at a cost of about $24.5 million per year.  In FY2002, Colorado spent slightly more than half this amount ($14.9 million).  At $3.39 per capita, Colorado’s FY2002  tobacco control spending was about 5 percent below average per capita spending in other states.^[194]  Colorado was one of 42 states to appropriate some portion of their tobacco lawsuit settlement funds to tobacco prevention in FY2002.^[195]  No other state funds were appropriated, with the balance drawn from federal and non-governmental sources.

Colorado could significantly improve its overall tobacco control efforts by raising the state’s cigarette excise tax rate and investing the increased revenues in prevention.  Numerous studies have shown that increases in the price of cigarettes reduce the prevalence of smoking and the number of cigarettes smoked, especially among youth.^[196]  At 20¢ per pack of cigarettes, Colorado’s tax is less than half the national average.^[197]  Like the state’s alcohol excise taxes, the cigarette tax is not indexed for inflation, so its value erodes over time.  The current tax is worth only 60 percent of its value in 1986, when it was last raised.^[198]  In only ten states do combined federal and state taxes account for a smaller percentage of the retail price of cigarettes than is the case in Colorado.^[199]

A substantial increase in Colorado’s cigarette excise tax is long overdue, and would play a major role in reducing smoking.  Whether or not Colorado raises the tax rate, some portion of the current revenues generated by the tax—$58 million in FY2001—should be dedicated to tobacco control.  Five states, including neighboring Arizona and Utah, already devote some portion of their cigarette tax revenues to tobacco control activities.^[200]  Under a 1991 amendment to the Colorado Constitution known as the Taxpayers’ Bill of Rights (TABOR), any increase in state tax rates requires the majority approval of Colorado voters on a ballot initiative.  Dedicating the revenues from the cigarette excise tax at its current level, however, could be accomplished by executive order.

Alcohol and Illicit Drugs
With respect to alcohol and illicit drugs, the crucial challenge facing Denver—and the rest of Colorado—is closing the treatment gap.  As described in Chapter II, Drug Strategies estimates that  between 45,000 and 60,000 Denver residents need treatment for substance  abuse  in any given year, but at most only 7,000 actually receive treatment (not including those who enter drinking driver and detoxification programs).^[201]  The unmet need for treatment is a pressing problem in the rest of the state as well.  Among an estimated 200,000 to 250,000 non-Denver residents who need treatment, only 25,000 receive it.^[202]

Among Denver residents, the number of admissions to publicly-funded treatment programs  has declined in recent years, according to data maintained by ADAD.  During the five-year period FY1998-2002, treatment admissions among Denver residents averaged 2,397 per year, down 17 percent compared to the previous five-year period.^[203]  Given the substantial growth in Denver’s overall population in recent years, the declining number of treatment admissions is even more worrisome.  For every 100,000 Denver residents age 12 and older, there were an average of 515 treatment admissions each year from FY1998-2002, 23 percent lower than in FY1993-1997 (668 per 100,000).  Although it is too early to tell, an upswing in admissions during the first half of FY2002 may signal the beginning of a new trend of increased treatment participation among Denver residents.

In Colorado as a whole, admissions to publicly-funded treatment programs have been on the rise.  The annual average of 16,910 admissions from FY1998-2002 was up 10 percent from the 15,409 average of the previous five years.^[204]  However, given the state’s overall population growth, Colorado still appears to be losing ground in the effort to close the treatment gap.  For every 100,000 Coloradans age 12 and older, there were 473 treatment admissions per year from FY1998-2002, a 4 percent drop compared to the previous five-year period (492 per 100,000).

Spending on Treatment in Colorado

Treatment services are financed in four basic ways: government grants or government-financed health insurance; private health insurance (typically employer-sponsored); out-of-pocket payments by the treatment client or the client’s family; and philanthropy.  Treatment spending from all sources grew by just 1.6 percent per year from 1992-1997, only half the growth rate in health care spending overall.^[205]  Treatment spending is also slight by comparison to the total economic costs that alcohol and drug abuse impose on the nation.  In 1997, alcohol and drug abuse cost Americans an estimated $320 billion, of which treatment expenditures accounted for less than 4 percent.^[206]  Even within this picture of meager spending on treatment nationwide, Colorado has lagged behind.

Public Funding for Substance Abuse Treatment
Governmental sources have accounted for an increasing share of total U.S. spending on treatment in recent years, rising from 50 percent in 1987 to 62 percent in 1997 (the most recent year for which comprehensive data are available).^[207]In 1997, the $7.345 billion in public dollars spent on treatment nationwide amounted to about $27 per U.S. resident.^[208]  By comparison, FY2002 public funding for treatment in Colorado—from federal and state sources—amounted to only $7.50 per Colorado resident.^[209]  Colorado’s comparatively low per capita spending on treatment reflects three major factors:  relatively low investment of the state’s own General Fund dollars in treatment; sharp limits on the extent to which Medicaid can cover treatment in Colorado; and  failure to use state alcohol excise tax revenues for treatment.

Federal and State Grant Funds for Treatment
Colorado budgets roughly $22 million per year for community-based treatment services, with federal grants comprising about half the total.^[210]  The state’s Alcohol and Drug Abuse Division (ADAD)  allocates the treatment dollars by region and contracts with managed service organizations  to deliver treatment services through a network of local providers in each region.  Denver and its five neighboring counties comprise one such region, and  typically receive slightly more than half of  ADAD’s community treatment funds.  In FY2001, treatment funding for the Denver region totaled $11.7 million, an 11 percent increase since FY1996.  (By comparison, General Fund appropriations for the Colorado Department of Corrections rose 79 percent over the same period.^[211])  Of the ADAD funds allocated to the Denver region, 30 percent are targeted to detoxification and 70 percent to treatment.

Medicaid Coverage for Treatment
Medicaid, funded jointly by the states and the federal government, is the largest provider of health coverage in the United States, and the principal source of health coverage for Americans living in poverty.^[212]  In Colorado, the state’s contribution is complemented by nearly equal funding from the federal government.

Nationally, Medicaid accounts for nearly 20 percent of all  expenditures on alcohol and drug abuse treatment, including nearly one in three public dollars spent on treatment.^[213]  In Colorado, however, Medicaid has played a comparatively minor role in treatment funding, with coverage restricted to pregnant or postpartum women and to hospital-based medical detoxification.

Since 1991, Colorado Medicaid has paid for outpatient treatment for women who are pregnant or within 60 days of having given birth; with some 300 clients a year, expenditures have averaged $200,000 annually.  With the inclusion of Medicaid coverage for residential treatment beginning in FY2001, spending increased to nearly $350,000.^[214]  In addition, Medicaid pays for $1.2 million in hospital-based detoxification services provided to about 375 patients per year.^[215]  Colorado’s annual Medicaid expenditures on treatment (including the federal match) total about 32¢ per resident, only a fraction of the U.S. average ($8.31 per capita).^[216]

Under federal rules, expanding substance abuse treatment coverage for a particular segment of Colorado’s Medicaid population requires that the state apply for a federal waiver.  In Spring  2002, the Colorado General Assembly considered a bill that would have authorized the state’s Department of Health Care Policy and Financing to apply for a federal waiver to extend Medicaid treatment coverage to approximately 50,000 poor parents and their children.^[217]  (Another 90,000 elderly poor and persons with disabilities enrolled in Medicaid would not have been included in the expansion of substance abuse coverage.^[218])  The Senate approved the waiver bill, but the provision died in the House of Representatives.^[219]

Alcohol Excise Tax Revenue
As described in Chapter III, Colorado has among the lowest alcohol excise tax rates in the country.  Research has shown that increasing the price of alcohol reduces drinking and related problems, including accidents, violence and disease.^[220]  Youths and young adults are especially sensitive to alcohol price increases, as are heavy drinkers, who spend a large proportion of their personal income on alcohol.^[221]  Colorado’s revenue from alcohol excise taxes amounts to nearly $30 million per year.^[222]  This revenue represents a logical, but as yet untapped, source of additional funding for treatment.  Indeed, in 1976, when the Colorado General Assembly last raised the excise tax on beer, the explicit intent was that the increased revenues would fund alcohol treatment programs.^[223]  The idea retains its appeal.  According to a 1998 national survey sponsored by the Robert Wood Johnson Foundation, four in five Americans favor increasing alcohol taxes by 5¢ per drink if the revenue is used to prevent underage drinking and to fund alcohol treatment programs.^[224]

If Colorado increased its alcohol excise tax rates by as little as 1¢ per drink, the state could generate an additional $20 million annually.^[225]   Larger alcohol excise tax increases would provide  stronger prevention benefits as well as more funding for treatment.   A new  revenue stream of $20 to $30 million a year would provide an enormous boost to publicly-funded treatment in Colorado, with negligible impact on state budgeting flexibility.  In FY2001, alcohol excise tax proceeds accounted for less than four-tenths of 1 percent of Colorado’s $8.2 billion in net revenue collections.^[226]  Raising Colorado’s alcohol excise tax rates would require approval of the voters by ballot initiative, but devoting the revenues generated by the taxes at their current levels could be achieved by executive order.

Private Health Insurance Coverage for Substance Abuse Treatment
According to the 1999 National Household Survey on Drug Abuse, nearly 9 million American adults meet the diagnostic criteria for addiction to alcohol or other drugs.  Sixty percent of these people with addictions are employed full-time.^[227]  To the extent that private health insurance policies provide coverage for substance abuse treatment on par with benefits for other illnesses, more people who need treatment are likely to receive it, without relying on public funds.  Private insurers, though, have historically viewed their role as covering only medical care for the acute health problems that result from substance abuse and addiction, not rehabilitative treatment services.^[228]  

When employer-sponsored insurance plans do cover alcohol and drug treatment, the services are typically subject to tighter restrictions than are applied to medical care for physical illnesses.  The restrictions include:  lower limits on the number of days of inpatient hospital care; limits on the number of outpatient visits per year and reduced coinsurance levels; and annual or lifetime maximum dollar amounts.^[229]  Less than 5 percent of the nation’s 38 million full-time employees at medium and large businesses have employer-provided insurance with equal coverage for substance abuse treatment.  Another 60 percent of these 38 million employees have some form of substance abuse coverage, but with significant restrictions.^[230]  From 1987-1997, insurance payments for all health services grew at an annual rate of 5.4 percent; by contrast, payments for treatment actually fell by 0.6 percent per year.^[231]  This trend toward an even further diminished role for private insurance in facilitating substance abuse treatment has prompted a wave of legislative efforts to mandate more extensive coverage.

Since the mid-1990s, seven states have passed “parity” laws requiring that insurers provide the same level of benefits for the treatment of substance abuse as for any other health disorder.^[232]   Another eight states have enacted laws requiring some minimum level of coverage for substance abuse services, but still allowing for tighter restrictions on treatment compared to other  health care benefits.^[233]  In another 19 states, substance abuse parity was a high priority item on the Spring 2002 legislative agenda.^[234]  As of 2001, all health plans that participate in the Federal Employees Health Benefits program have been required to provide substance abuse and mental health treatment parity.^[235]

The push for insurance parity has been based on a growing understanding that addiction is a chronic health disorder, and buttressed by strong evidence that treatment works.  Concerns that parity would substantially raise insurance premiums have not been borne out.  The most comprehensive study to date projects at most a 0.3 percent increase in the total family premium as a result of full parity.^[236]

In Colorado, 1.8 million adults are enrolled in employer-sponsored health insurance plans.^[237]

An estimated 100,000 to 125,000 of these 1.8 million insured Coloradans need substance abuse treatment,^[238] so parity for treatment benefits could make a sizable contribution to closing the treatment gap, in Denver and statewide.  Current Colorado law mandates parity for certain mental health diagnoses, but does not require insurers to offer benefits for substance abuse disorders, much less mandate that they be equal to benefits for other illnesses.  A bill before the Colorado General Assembly in the Spring of 2002 would have mandated comprehensive mental health and substance abuse parity.^[239]  The Senate passed the bill, but the measure eventually died in the House of Representatives Committee on Health, Environment, Welfare and Institutions.^[240]

The Price of Incarceration, The Need for Treatment

As the incarceration statistics presented in Chapter III make clear, Colorado legislators have,  without any doubt, been tough on drugs.  Under current law,^[241] conviction for possessing or distributing an ounce or more of drugs such as cocaine, heroin or methamphetamine triggers mandatory minimum prison sentences.  Possession offenders face prison terms between 2 and 8 years. First time distribution offenders face between 4 and 16 years, and repeat distribution offenders face 8 to 24 years.  Putting more drug offenders behind bars and sentencing them to longer terms makes claims on state budgets for years to come.  For example, the 2,640 drug offenders committed to prison in Colorado in FY1998 and FY1999 will cost the state more than $195 million in the ensuing years.^[242]

Between FY1992 and FY2002, the Corrections Department operating budget more than tripled, rising from $144 million to $478 million.^[243]  In addition, the Corrections Department spent an average of $72 million a year on new prison construction, renovation and maintenance, accounting for nearly one-quarter of the state’s total capital construction appropriations.^[244]

The rapid increase in prison spending has occurred despite the 1991 TABOR amendment and  related statutes limiting the growth in total General Fund appropriations to 6 percent above the previous year’s level.  General Fund appropriations for the Corrections Department grew at an annual rate of more than 23 percent from FY1992-2002, not including construction appropriations.^[245]  Given the 6 percent restriction on the growth of total General Fund appropriations, the highly accelerated growth in prison spending over the last decade has left fewer dollars available for other public purposes.  Spending on prison operations grew at twice the rate of health and human services spending, and at nearly three times the rate of education spending.^[246]

As has occurred in many other states, doubts about the efficacy of incarcerating scores of drug users have been sharpened by the recent economic downturn.^[247]  The explosive growth in prison spending that took place during the economically-flush 1990s cannot be sustained in a new era of budget constraints.  In an effort to rein in prison costs and at the same time increase funds for offender treatment, the 2002 General Assembly approved legislation reducing penalties for certain drug use offenses and for drug possession offenses involving one gram or less.  With fewer low-level offenders being sentenced to prison, the cost savings (projected to be about $2 million a year) would have been invested in treatment for offenders.  However, Governor Bill Owens vetoed the bill.^[248]

During the same session, as part of legislation reforming the state’s asset forfeiture procedures, the General Assembly mandated that 50 percent of the proceeds from confiscated property be earmarked for detoxification and treatment.  These new treatment funds, projected to total $1 to $2 million a year, will be distributed directly to the treatment managed services organizations in each region of the state.^[249]

The impact of substance abuse on the criminal justice system extends well beyond the issue of how to deal with drug law offenders.  Substance abuse is pervasive among criminal offenders,  regardless of offense.  Half of Denver arrestees are dependent on alcohol or illicit drugs, as are one-third of arrestees in the rest of the state.^[250]  As of June 2000, 77 percent of Colorado prisoners —nearly 11,000 inmates—were identified at intake as needing treatment for substance abuse.^[251]   More than 80 percent of all state prisoners released during the year 2000 were in need of treatment.  Of the 4,350 prisoners released in 2000 who had been identified at intake as needing treatment, 70 percent received no treatment at all while incarcerated.^[252]

Given the expense of incarceration (nearly $27,000 per inmate per year^[253]) and the high proportion of Colorado prisoners with alcohol and drug problems, prison-based treatment followed by aftercare in the community is a critical means of reducing crime and spending on criminal justice.  Failure to provide adequate treatment, including aftercare in the community, increases the likelihood that many drug-involved offenders will soon return to prison.  According to the National Institute of Justice, between 65 and 70 percent of all untreated parolees with histories of cocaine or heroin use will return to drug use within three months of release.^[254]  By achieving even modest reductions in the rate at which former prisoners return to drugs, treatment can help prevent crime and avoid millions of dollars in spending on public safety and criminal justice.

Public Opinion and State Policy Reform

A greater emphasis on prevention and treatment and a reduced role for incarceration would begin to lessen the costs of substance abuse in Colorado.  The prospects for the comprehensive substance abuse strategy now being launched in Denver would be considerably brightened by a substantial increase in the state’s investment in prevention and treatment.  A July 2001 statewide survey found that Colorado voters favor just such a shift in emphasis, with strong support for change spanning all demographic categories.^[255]

Conducted for the Rocky Mountain Peace and Justice Center by Ridder/Braden, Inc., the survey of active voters found that few consider current policies effective in reducing drug use or the supply of illicit drugs.  Statewide, only 2 percent of voters consider the “war on drugs” to have been “very effective” in reducing use, and only 3 percent consider it “very effective” in reducing supply.  On the other hand, the vast majority of Colorado voters believe treatment is an effective way to reduce drug use (86 percent) and to reduce drug-related crime (80 percent).  Consistent with this belief, 74 percent of Colorado voters favor “increasing state funding to greatly expand the availability of treatment.”  Support for increased treatment funding is especially pronounced in Denver (84 percent), but is consistently high across all major demographic categories in the state, including urban (79 percent), suburban (77 percent) and rural communities (75 percent).  Significantly, support for more treatment funding is even stronger among Colorado’s Republican voters (78 percent) than among Democrats and independents (66 percent).

Support is similarly strong (73 percent) in favor of decreasing criminal penalties for people possessing small quantities of drugs and investing the prison cost savings in prevention and treatment programs—as provided in legislation approved by the Colorado General Assembly in Spring 2002.  Denver voters are especially supportive of such a reform (90 percent in favor), and  voters in the rest of the Colorado were also firmly in agreement (70 percent).  Virtually no voter support exists for reducing state spending on health, education or transportation in order to pay for more prisons—a pointed repudiation of the spending patterns of the past decade.  Specifically, only 7 percent of voters favor reducing state spending on public health and substance abuse treatment services to pay for prisons.

In sum, a sizable majority of Colorado voters favors a considerable shift in state funding priorities toward treatment and away from incarceration.  In light of these survey findings and the important policy changes considered during the 2002 legislative session, the momentum for constructive reform is growing in Denver and in the rest of Colorado.

ENDNOTES: